Use of vascularised free fibula in limb reconstruction (for non-

malignant defects)Shahid Hameed, Rana Hassan Javaid Ehtesham-ul-Haq, Rao Saood Ahmed, Abdul Majid, Muhammad Waqas, Ayesha

Aslam, Omamah Yusuf, Ahsin Masood Butt, Ghazanfar Ali ( Department of Plastic and Reconstructive Surgery, Combined

Military Hospital, Rawalpindi. )

Abstract

The case series was conducted at the Department of Plastic Surgery, Combined Military Hospital,

Rawalpindi, from June 2009 to May 2011, and comprised 19 patients in whom free fibula flap was

performed for upper and lower limb reconstruction, using SPSS 16. Results showed that flap survival

was 100%. One (5.2%) flap was re-explored for venous congestion and was salvaged. One (5.2%)

patient of congenital pseudoarthrosis of tibia had a fracture of the fibula and was treated with external

fixation. Average follow up was 8 months. Mean union time and full weight-bearing was 6.5±1.34

months (range3-8 months) and 9 months, respectively. No recurrence of pseudoathrosis was observed

until the last follow up, with only a 1.5cm length discrepancy in one patient. The results proved that a

microvascular free fibular flap heals rapidly, causes early functional recovery and it can be raised as an

osteocutaneous flap.

Keywords: Pseudoarthrosis, Trauma, Free flap.

Introduction

Reconstruction of large defects (>6cm) in long bones of the limbs poses a challenge to the

reconstructive surgeon with regards to limb length preservation, function and cosmesis. There can be

multiple causes of these defects e.g. trauma, infection with osteomyelitis and oncologic resection which

in turn can be with or without soft tissue loss.

Various reconstruction modalities are present, each having its own benefits and drawbacks. The two

most acceptable techniques for large long bone defects include the use of massive bony allografts and

free composite tissue flaps.

Non-vascularised allografts provide a biological spacer with strong cortical bone and can be accurately

matched to conform to the configuration of a bony defect. The use of allograft has fewer host/donor-

site morbidity.1 Allografts, however, have many disadvantages, including their lack of blood supply,

lack of osteogenic cells, and potential for immunologic reaction, slow, superficial and incomplete

healing, high non-union rate and pre-disposition to infection and fracture.2-8

With the advent of microvascular surgical reconstruction, techniques using free vascularised bone have

become well-described and well-established.9,10

Potential donor site for osteocutaneous free flaps is the vascular system supplied by the subscapular

artery, where a lateral or medial segment of the scapula can be included in composite grafts.11,12 Other

flaps, such as the lateral arm flap and the radial forearm flap, can also be modified as an

osteofasciocutaneous flap when a bone segment from the lateral and distal humerus or from the radius

is included.13,14 Another potential donor site for microvascular bone segments is the iliac crest, but its

curvature limits reconstruction of long diaphyseal bone or requires multiple osteotomies.15

Probably the most popular possibility for bone-only and free composite tissue harvest is the free fibula

transplantation. The first microvascular fibula transfer was performed by Ueba and Fujikawa in 1973

and Taylor et al. in 1974.16,17 In 1977, Weiland et al. reported the first reconstruction of long bones

with vascularised fibula after tumour resection.18 This option offers good available length of bone,

good pedicle size, minimal donor site morbidity, shortened union time compared with the allograft and

the possibility of using its proximal end for joint restoration. The composite free fibula flap can provide

a skin paddle, soft tissue and muscle to reconstruct complicated defects.

Vascularised free fibula is also a treatment modality for congenital pseudoarthrosis of tibia.19 It is a rare

disease which usually becomes evident within a child's first year of life, but may be undetected up to

the age of 12 years.20 It is characterised by segmental osseous weakness, resulting in anterolateral

angulation of the bone. The osseous dysplasia leads to tibial fracture and non-union. Tibial bowing and

reduced growth in the distal tibial epiphysis may result in shortening.

Our unit has previously published results of salvage of the upper limb using vascularised fibula flaps.21

Here we describe our results with free fibular flaps for limb salvage in patients with defects resulting

from non malignant conditions and congenital pseudoarthrosis of tibia.

Patients and Methods

A total of 58 free fibular flaps were performed at the Plastic Surgery Department of the Combined

Military Hospital, Rawalpindi, over a two-year period from June 2009 to May 2011. Thirtytwo free

microvascular fibular flaps were performed in upper and lower limbs out of which 19 were performed

for upper and lower limb reconstruction due to defects arising from non-malignant conditions. Out of

these, 11 were oseocutaneous flaps while the rest were bone-only flaps.

Fourteen patients had bone loss due to trauma (most of these patients were serving soldiers injured

during combat) and 5 patients had Congenital Pseudoarthrosis of the tibia.

The type of psuedoarthrosis was evaluated according to Crawford classification.22 (Figure-1).

Three patients had Type III and 2 had Type IV psuedoarthrosis.

Reconstruction was done in 8 Upper limbs and 11 lower limbs (Table).

A pedicled latissimus dorsi flap was done for soft tissue coverage of elbow defect in one patient three

months after which free fibula flap was done. Another patient underwent radial nerve transfer for radial

nerve injury four months prior to an osseocutaneous free fibula for humerus reconstruction.

The orthopaedic team performed the resection. The reconstructive effort was started simultaneously

with the raising of the fibula. In all patients whom osteocutaneous fibula was done, perforators were

marked before general anaesthesia with a Huntleigh SD2 healthcare hand-held Doppler. The right

fibula was harvested in all except 4 patients who underwent reconstruction of defects in the tibia as the

lesions were on the right side.

Fibular dissection was done through a lateral approach under tourniquet control. Any variation in blood

supply was noted. Length of the fibula required was pre-operatively assessed by measuring the defect

on the X-ray, taking into account the disparity in size between the X-ray and actual defect. Per-

operatively the bone defect created by the resection was measured by the orthopaedic surgeon and the

length of the fibula required was communicated. The maximum length was harvested to ensure the

maximum possible length of the pedicle.

After resection was complete the patient was given 5000 international units of heparin intravenously

(IV) and the fibular pedicle was divided The fibula was handed over to the orthopaedic team with one

member of the plastic surgery team working with them for insetting of the bone and protecting the

pedicle throughout the insetting/fixation of the bone. All anastamosis were done in a non-traumatised

area under loupe magnification (x4). In the recipient site, the fibular graft was inserted into the

medullary canal of the long bone. Additional stability was provided by cortical screws or locking

plates. All free flaps with a skin paddle were monitored clinically by colour, temperature, capillary

refill and pattern of bleed on scratching. To monitor bone-only fibular flaps, three-phase bone scan was

done within the first 48 hours after surgery. For the donor lower limb an above-knee plaster of Paris

(POP) slab was given for 4 weeks after which partial weight-bearing was started at 6 weeks. In cases of

lower limb reconstruction partial weight-bearing was started at 12 weeks after consultation with an

orthopaedic surgeon.

Aeroplane splint slab was used for arm immobilisation when reconstruction of humerus was done.

Osseous union was defined as described by Gebert et al. and included attenuation or absence of

osteotomy line, presence of external bridging callus, or bony trabeculae spanning the osteosynthesis

site.23

Statistical analysis was done using SPSS 16.0. Continuous variables were expressed as mean ±

standard deviation, whereas frequencies and percentages were shown for nominal variables.

Drawings illustrate Crawford's classification of congenital pseudarthrosis of tibia. Patients with all

types present with anterolateral bowing of tibia. In type I, the medullary canal is preserved. Cortical

thickening might be observed. Type II is defined by presence of thinned medullary canal, cortical

thickening, and tabulation defect. The dominant finding in type III is a cystic lesion, which may be

fractured. In type IV, pseudarthrosis is present with tibial and possibly fibular non-union.

Results

Out of the 19 patients in the study, 6 (32%) were females the rest (13, 68%) were males. The mean age

for patients with congenital pseudoarthrosis was 8.4±2.79 years, and for rest of the patients was

33.86±8.43 years.

The average raising time of the free fibula was 75-90 mins for bone-only flap. Osteocutaneus flaps took

a little longer to raise compared to bone-only flaps (90-105 mins). Total Operating time including the

orthopaedics team and reconstruction time was 6-11 hours with mean 6.15±1.67 hours. Maximum

length of the fibula was 22cm for tibia and minimum length of fibula was 7cm (for congenital

pseudoarthrosis of the tibia).

Flap survival was 100%. One Flap was re-explored for congestion 20 hours post-operatively; a venous

clot was found intra-operatively. The flap was salvaged. One patient of congenital pseudoarthrosis of

tibia had a fracture of the fibula and was treated with external fixation.

Average followup was 8 months. All patients had achieved bone union on their last followup visit,

including patients of pseudoarthrosis. Mean union time was 6.5±1.34 months (range: 3-8 months) as

determined clinically and radiologically by evidence of bridging of three of the four cortices on plain

radiographs.

The mean time to full weight-bearing was 9 months, and all patients were pain-free and able to walk

without supportive devices.

At final followup there was no recurrence of pseudoathrosis until the last followup, with only a 1.5cm

length discrepancy in one patient.

Three of the cases are described here individually:

Case-1

A 13-year-old female with type IV pseudoarthrosis operated previously at another hospital (Figure-2).

Case-2

A young soldier with segmental loss of ulna due to gunshot wound was treated. He was subjected to

9cm free osteocutaneous fibula flap. Anastamosis was done with the ulnar artery and its 2 vena

commitments (Figure-3).

Case-3

A young soldier with gunshot wound resulting in segmental loss of humerus right and radial nerve

injury was also treated. Radial nerve transfer was done. After four months, free fibula osteocutaneous

flap was done (Figure-4).

Discussion

Free Fibula has been extensively used for reconstruction of limb defects post-tumour resection. Studies

of it as a viable option for reconstruction of long bone defects due to other causes remain scarce and

hard to find especially in local literature.

Since Taylor et al, numerous studies have demonstrated that microvascularised transfer of bone can be

effective for the reconstruction of large skeletal defects, including those due to trauma, resection of a

tumour, infection and congenital tibial pseudarthrosis.24-26

Worldwide, the free vascularised fibular graft (FVFG) has become the most commonly transferred

vascular autograft for reconstructing segmental bone defects.27

Microvascular transplantation of an osteocutaneous fibula graft includes the advantage of a diaphyseal

bone that is sufficient in length and stability for reconstruction of upper extremity as well as lower

extremity bone defects.28,29 In addition, the vascular pedicle of the graft is of sufficiently large

diametre to facilitate microvascular anastamosis.

Also the advantages of use of vascularised grafts as compared with use of non-vascularised grafts have

been demonstrated experimentally and clinically in skeletally mature individuals. These advantages

include skeletal healing without creeping substitution of the graft from the surrounding host bone; more

rapid incorporation and union; lower rates of fracture, infection, resorption, and non-union; the option

of using the grafts for the treatment of established infections and segmental defects larger than five

centimetres; greater initial strength; remodelling in a manner similar to that of viable bone; the ability

to respond to biomechanical loading physiologically; increased hypertrophy; and a decreased duration

of immobilization after implantation.30

Jupiter et al. demonstrated that after secondary reconstruction procedures, mature vascularised fibular

grafts respond in a manner similar to normal cortical bone.31 Fibulas will hypertrophy through a

process of pressure transport, microfracture and callus formation. We have also seen this in long-term

followup of our patients.

Reconstruction using vascularised fibula graft alone takes as early as three months to unite.32 In other

studies, an average time of three to five months is needed for union.33 Ninety per cent of the patients

achieved union at average of 7.6 months in a study conducted by Hsu et al,34 which is similar to the

time the fibula took to achieve union in our patients (6.5 months).

We also used it as an osteocutaneous flap in 11 cases. Other studies have also shown advantages of

using a skin paddle. They show that monitoring of graft perfusion is clinically possible when a skin

paddle is left attached to the fibula.35

We have also observed that primary closure (without using a split thickness skin graft) becomes easier

once a skin paddle is used, as usually the recipient skin and soft tissue consists of scar tissue.

The complication rate after composite tissue transplantation is low, but the difficulty and length of the

procedures may be disadvantageous.

In the past, some authors thought that the FVFG could only be done at specialised centres and was

time-consuming. These grafts took years to hypertrophy and often fractured one or more times before

re-modelling was complete. The grafts often failed to unite to the recipient osseous tissue at one or both

ends.36

However, in our study, only one fracture and no non-union of the vascularised fibular grafts were

encountered, which is similar to the study conducted by Sun et al37 (although the defects were post

osteomyelitis).

Recent studies show that donor-site morbidity after harvest of a free osteocutaneous fibula segment is

low.38,39 The most frequent complaints are pain, dysesthesia, and a feeling of ankle instability. There

was no morbidity at the donor site in our study.

The interpretation of our results of reconstruction for congenital pseudoarthrosis need to be

consolidated with a longer followup till skeletal maturity and with a larger no of patients.

Conclusion

Microvascular free fibular flaps heal more rapidly with fewer complications. There is earlier functional

recovery than conventional non-vascularised grafts and it can be raised as an osteocutaneous flap. It

provides a dynamic option to the plastic surgeon for 3 dimensional reconstruction of large complex

defects located in poorly vascularised wound beds.

Acknowledgement

We would like to acknowledge the contribution of Mr Darren Chester (Consultant Plastic Surgeon MB

ChB, MPhil, MRCS, FRCS (Plast.) University Hospital Birmingham UK, for revising the article

critically and reviewing its intellectual content.

Refrences

1. Moran SL, Shin AY, Bishop AT. The use of massive bone allograft with intramedullary free fibular

flap for limb salvage in a paediatric and adolescent population. Plast Reconstr Surg 2006; 118: 413-9.

2. Stevenson S. Biology of bone grafts. Orthop Clin North Am 1999; 30: 543-52.

3. Ortiz-Cruz E, Gebhardt MC, Jennings L, Springfield DS, Mankin HJ. The results of transplantation

of intercalary allografts after resection of tumors: A long-term follow-up study. J Bone Joint Surg Am

1997; 79: 97-106.

4. Cara JA, Laclériga A, Cañadell J. Intercalary bone allograft: 23 tumor cases followed by 3 years.

Acta Orthop Scand 1994; 65: 42-6.

5. Makley JT. The use of allograft to reconstruct intercalary defects of long bone. Clin Orthop Relat

Res 1985; 197: 58-75.

6. Berry BHJr, Lord CF, Gebhardt MC, Mankin HJ. Fractures of allografts: Frequency, treatment and

end-results. J. Bone Joint Surg Am 1990; 72: 825-33.

7. Brunelli G, Brunelli G. Free microvascular fibular transfer for idiopathic femoral head necrosis:

Long-term follow-up. J Reconstr Microsurg 1991; 7: 285-95.

8. Weiland AJ. Current concepts review: vascularized free bone transplant. J Bone Joint Surg 1981; 63:

166-9.

9. Gebert C, Hillman A, Schwappach A, Hoffmann Ch, Hardes J, Kleinheinz J et al. Free vascularised

fibular grafting for reconstruction after tumor resection in the upper extremity. J Surg Oncol 2006; 94:

114-27.

10. Gherlinzoni F, Picci P, Bacci G, Campanacci D. Limb sparing versus amputation in

osteosarcoma.Correlation between local control, surgical margins and tumor necrosis: Istituto Rizzoli

experience. Ann Oncol 1992; 3(Suppl 2): 3-7.

11. Smith RB, Henstrom DK, Karnell LH, Chang KC, Goldstein DP, Funk GF. Scapula osteocutaneous

free flap reconstruction of the head and neck: impact of flap choice on surgical and medical

complications.Head Neck 2007; 29: 446-52.

12. Sauerbier M, Erdmann D, Bickert B,Whitteman M, GermannG.[Defect coverage of the hand and

forearm with a free scapula-parascapular flap].Handchir Mikrochir Plast Chir 2001; 33: 20-5.

13. Karamürsel S, Ba?datlý D, Markal N, Demir Z, Celebio?lu S. Versatility of the lateral arm free flap

in various anatomic defect reconstructions.J Reconstr Microsurg 2005; 21: 107-12.

14. Militsakh ON, Werle A, Mohyuddin N, Toby EB, Kriet JD, Wallace DI, Girod DA, Tsue TT.

Comparison of radial forearm with fibula and scapula osteocutaneous free flaps fororomandibular

reconstruction. Arch Otolaryngol Head Neck Surg 2005; 131: 571-5.

15. Serafin D. The groin-iliac crest-deep circumflex iliac artery flap. In: Serafin D (ed.) Atlas of

Microsurgical Composite Tissue Transplantation. Philadelphia: Saunders; 1996; pp 525-35.

16. Ueba Y, Fujikawa S. Nine years follow up of a vascularized fibular graft in neurofibromatosis: a

case report and literature review. Jpn J Orthop Trauma Surg 1983; 26: 595-600.

17. Taylor GI, Miller GD, Ham FJ. The free vascularised bone graft. A clinical extension of

microvascular techniques. Plast Reconstr Surg 1975; 55: 533-44.

18. Sowa DT, Weiland AJ. Clinical applications of vascularized bone autografts. Orthop Clin North Am

1987; 18: 257-73.

19. Choi IH, Cho TJ, Moon HJ. Ilizarov Treatment of Congenital Pseudarthrosis of the Tibia: A Multi-

Targeted Approach Using the Ilizarov Technique. Clin Orthop Surg 2011; 3: 1-8. doi:

10.4055/cios.2011.3.1.1.

20. Delgado-Martinez AD, Rodriguez-Merchan EC, Olsen B. Congenital pseudarthrosis of the tibia. Int

Orthop 1996; 20: 192-9.

21. Rashid M, Hafeez S, Zia ul Islam M, Rizvi ST, ur Rehman S, Tamimy MS, et al. Limb salvage in

malignant tumours of the upper limb using vascularised fibula. J Plast Reconstr Aesthet Surg 2008; 61:

648-61.

22. Crawford AH. Neurofibromatosis in children. Acta Orthop Scand Suppl 1986; 218: 1-60.

23. Gebert C, Hillman A, Schwappach A, Hoffmann Ch, Hardes J, Kleinheinz J, Gosheger G. Free

vascularised fibular grafting for reconstruction after tumor resection in the upper extremity. J Surg

Oncol 2006; 94: 114-27.

24. Ridha H, Bernard J, Gateley D, Vesely MJ. Reconstruction of large traumatic segmental defects of

the femur using segmental allograft with vascularized fibula inlay. J Reconstr Microsurg 2011; 27: 383-

90.

25. Bach AD, Kopp J, Stark GB, Horch RE. The versatility of the free osteocutaneous fibula flap inthe

reconstruction ofextremities after sarcoma resection. World J Surg Oncol 2004; 2: 22. doi:

10.1186/1477-7819-2-22.

26. Iamaguchi RB, Fucs PM, Carlos da Costa A, Chakkour I, Gomes MD. Congenital pseudoarthrosis

of the tibia - results of treatment by free fibular transfer and associated procedures - preliminary study.

J Pediatr Orthop B 2011; 20: 323-9.

27. Gebert C, Hillmann A, Schwappach A, Hoffmann Ch, Hardes J, Kleinheinz J, Gosheger G. Free

vascularised fibular grafting for reconstruction after tumor resection in the upper extremity.J Surg

Oncol 2006; 94: 114-27.

28. Zaretski A, Amir A, Meller I, Leshem D, Kollender Y, Barnea Y, et al. Free fibula long bone

reconstruction in orthopedic oncology: A surgical algorithm for reconstructive options. Plast Reconstr

Surg 2004; 113: 1989-2000.

29. Heitmann C, Erdmann D, Levin LS. Treatment of segmental defects of the humerus with an

osteoseptocutaneous fibular transplant. J Bone Joint Surg Am 2002; 84: 2216-23.

30. Shea KG, Coleman SS, Coleman DA. Growth of the proximal fibular physis and remodeling ofthe

epiphysis aftermicrovascular transfer. A case report. J Bone Joint Surg Am 1997; 79: 583-6.

31. Jupiter J B, Palumbo MA, Nunley JA, Aulicino PL,Herzenberg JE. Secondary reconstruction after

vascularised fibular transfer. J Bone and Joint Surg Am 1993; 75: 1442-50.

32. Imran Y, Zulmi W, Halim AS. Skeletal Union Following Long Bone Reconstruction Using

Vascularised Fibula Graft. Singapore Med J 2003; 44: 286-7.

33. Weiland AJ, Moore JR, Daniel RK. Vascularised bone autografts. Experience with 41 cases. Clin

Orthop Relat Res 1983; 174: 87-95.

34. Hsu RW, Wood MB, Sim FH, Chao EY. Free vascularised fibular grafting for reconstruction after

tumor resection. J Bone Joint Surg Br 1997; 79: 36-42.

35. Giessler GA, Bickert B, Sauerbier M, Germann G. [Free microvascular fibula graft for skeletal

reconstruction after tumor resections in the forearm: Experience with five cases]. Handchir Mikrochir

Plast Chir 2004; 36: 301-7.

36. Green SA, Jackson JM, Wall DM, Marinow H, Ishkanian J. Management of segmental defects by

Ilizarov intercalary bone transport method. Clin Orthop Relat Res 1992; 280: 136-42.

37. Sun Y, Zhang C, Jin D, Sheng J, Cheng X, Liu X, et al. Free vascularised fibular grafting in the

treatment of large skeletal defects due to osteomyelitis. Int Orthop 2010; 34: 425-30.doi:

10.1007/s00264-009-0761-x.

38. Tang CL, Mahoney JL, McKee MD,Richards RR, Waddell JP, Louie B. Donor site morbidity

following vascularised fibular grafting. Microsurgery 1998; 18: 383-6.

39. Vail TP, Urbaniak JR. Donor-site morbidity with use of vascularised autogenous fibular grafts. J

Bone Joint Surg Am 1996; 78: 204-11.